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pain management in palliative care

Epidemiology: 1) pain is prevalent, debilitating & poorly undertreated in patients near the end of life 2) 60-90% of patients with advanced cancer experience moderate to severe pain during their illness 3) 50% of patients' pain is poorly controlled, despite the fact that adherence to simple pain management guidelines can control pain in > 80% of dying patients Management: - hydromorphone, fentanyl, methadone*, buprenorphine, hydrocodone show minimal pharmacokinetic changes in patients with renal failure [2] * methadone has a prolonged 1/2 life - respiratory depressant effects can persist for 36-48 hours - prolongs QTc, requires EKG to monitor QTc - interaction with other drugs that prolong QTc Notes: Barriers to optimal pain management: 1) inability to control pain in patients with advanced illness reflects a complex interplay of patient, physician & system- of-care factors 2) patient factors a) fear of side effects, addiction, overdose, or worsening pain reflects disease progression b) desire not to burden others, including perception of pain as a sign of weakness c) belief that severe pain is an in an inevitable part of the dying process d) fear that if the pain is treated early, they will run out of options for treatment in the future e) fear of adverse effects of analgesics f) fear that increasing pain means the disease is getting worse g) concern about being a 'good' patient 3) physician factors a) physicians routinely underestimate patients' pain b) fear - of addiction, abuse c) pain as a sign of failure of medical care 4) system-of-care factors a) organizational structure often discourages continuity of care b) underdeveloped systems for routine pain assessment & followup Ethical issues in pain management: - principle of double effect

Related

pain [odyn-] palliative care World Health Organization (WHO) pain ladder

References

  1. Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Davison NS Clinical pharmacology considerations in pain management in patients with advanced kidney failure. Clin J Am Soc Nephrol 2019 14(6):917-931 PMID: 30833302 PMCID: PMC6556722 Free PMC article